FORM 1 OF 4: PERSONAL INFORMATION

? Please mail all four original forms to:

WILLED BODY PROGRAM, P.O. Box 245045 Tucson, AZ 85724

? Make photocopies for your family, physician, and for your records.

? If you have additional questions, please call (520) 626-6083.

FORM 1 OF 4: PERSONAL INFORMATION

Date: ______________________________

Telephone number: _______________________________

Full name of donor (print): ____________________________________________________________________________

First

Middle

Last

Mailing address: ____________________________________________________________________________________

Street number

Street

Unit/Apt/Space

City, State, Zip: ____________________________________________________________________________________

If physical address is different from mailing address, list physical address:

__________________________________________________________________________________________________

County of residence: ____________________________ ; Within city limits (Select one):

On a reservation (Select one):

¡õ Yes ¡õ

No ; If ¡°Yes,¡± please specify: ____________________________________

Date of birth: _________________________________ ;

Month /

Day

Select one:

¡õ Male

¡õ Female

/ Year

Place of birth: ________________________________________ ;

City

¡õ Yes ¡õ No

County

Country of Citizenship: ______________________

State

Year Arizona residency began: __________________ ;

State resided in before Arizona: _______________________

Donor¡¯s Social Security Number: _________________ ;

U.S. Veteran (Select one):

Current marital status:

¡õ Never Married

¡õ Married ¡õ Widowed

¡õ Yes ¡õ No

¡õ Separated ¡õ Divorced

If married, spouse¡¯s full name (wife¡¯s maiden name): ______________________________________________________

First

Middle

Last

Donor¡¯s father¡¯s full name: ___________________________________________________________________________

First

Middle

Last

Donor¡¯s mother¡¯s full name (maiden name): _____________________________________________________________

First

Middle

Last

Primary occupation (if retired, prior to retirement): ________________________________________________________

Occupation¡¯s business or industry: _____________________________________________________________________

Highest level of education/degree: ______________________________________________________________________

Race (Select all that apply): ¡õ White ¡õ Black ¡õ American Indian (Specify Tribe): ________________________

¡õ Mexican ¡õ Spanish ¡õ Puerto Rican ¡õ Cuban ¡õ Other Hispanic (Specify): _______________________

¡õ Asian Indian

¡õ Vietnamese

¡õ Japanese ¡õ Chinese

¡õ Native Hawaiian

¡õ Filipino ¡õ Korean ¡õ Samoan

¡õ Other (Specify): __________________________________________

Revised 5/17/2019

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?

?

Please mail all four original pages to:

WILLED BODY PROGRAM, P.O. Box 245045 Tucson, AZ 85724

Make photocopies for your family, physician and for your records

If you have additional questions, please call (520) 626-6083

FORM 2 OF 4: MEDICAL QUESTIONNAIRE

Donor name: ______________________________________________________________________________________

Date of birth: _______________________________ Height: ___________________ Weight: ___________________

Surgical history:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Major health problems:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Any other information or advice you would like to give those you will be teaching:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Revised 9/13/2018

?

?

?

Please mail all four original pages to:

WILLED BODY PROGRAM, P.O. Box 245045 Tucson, AZ 85724

Make photocopies for your family, physician and for your records

If you have additional questions, please call (520) 626-6083

FORM 3 OF 4: AUTHORIZATION FOR ANATOMICAL DONATION

I, _____________________________________, hereby offer the use of my body after death to the University of Arizona

College of Medicine for health professional education and research. Once accepted, my body shall be used for health

professional education and research as determined by the University. Such determination may include transporting my

body to another educational institution for health professional education and research. I or my next of kin/representative

cannot specify the use of which my body will be used. Once my body is received by the University, I understand that

my donation cannot be revoked, except in very limited circumstances, by my next of kin/representative as outlined in

A.R.S. ¡ì 36-847. My body may be tested for Hepatitis B, Hepatitis C and HIV upon arrival at the University. My body

may be chemically preserved for a substantial period of time or may be used in an un-embalmed state as anatomical

material. Such uses may include dissection, medical procedures, physical examinations, and may be used for more than

one purpose. Parts of my body such as tissue, organs, limbs or skeletal material may be removed and separated from the

whole. Upon conclusion of my participation, or if it is determined that for any reason my body cannot be used by

the University, my body shall be cremated or undergo disposition by any legal means without notification to my

surviving next of kin/representative. I understand that my cremated remains WILL NOT be returned to my next of

kin/representative, but will be scattered by the University in accordance with Arizona State laws without the

possibility of recovery and without notification. I also understand that certain anatomical and/or pathological

structures that benefit health professional education and research may not be returned to the whole for disposition.

I understand that the University of Arizona reserves the right to refuse my donation for any reason at the time of my

death. If this situation arises, my designated next of kin/representative will be required to make alternate

arrangements. I also understand that I may revoke this document any time prior to my death pursuant to A.R.S. ¡ì 36-845.

The University of Arizona reserves the right to revise policies and procedures at any time without notification, acting

in compliance with Arizona State laws.

By signing my name below, I certify that I have read the above information. My signature also certifies my

understanding of and agreement to the information and policies listed on the Donor Information and Policy Guide.

_________________________________________________________________

Signature of donor

Date

_________________________________________________________________

Printed name of donor

WITNESSES

(YOU MUST HAVE TWO WITNESS SIGNATURES)

We, the undersigned, have witnessed the signing of this document by the donor as set forth in A.R.S. ¡ì 36-844.

________________________________________

Signature of witness

Date

________________________________________

Signature of disinterested witness

Date

(Cannot be a family member)

________________________________________

Printed name of witness

________________________________________

Printed name of disinterested witness

Revised 5/17/2019

?

?

?

Please mail all four original pages to:

WILLED BODY PROGRAM, P.O. Box 245045 Tucson, AZ 85724

Make photocopies for your family, physician and for your records

If you have additional questions, please call (520) 626-6083

FORM 4 OF 4: CONTACT INFORMATION

Donor name: ______________________________________________________________________________________

Please note: This information is required in order to verify death certificate information at the time of death.

Next of kin/Representative Contact Information

Name: ___________________________________________________________________________________________

Relationship to donor: ______________________________________________________________________________

Street address: ____________________________________________________________________________________

City: ____________________________________ State: _______________________ Zip: _______________________

Telephone number(s): ______________________________________________________________________________

Email address: ____________________________________________________________________________________

Alternate Contact Information

Name: ___________________________________________________________________________________________

Relationship to donor: ______________________________________________________________________________

Street address: ____________________________________________________________________________________

City: ____________________________________ State: _______________________ Zip: _______________________

Telephone number(s): ______________________________________________________________________________

Email address: ____________________________________________________________________________________

Revised 9/13/2018

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